Basic Information
| Provider Information | |||||||||
| NPI: | 1699883884 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT SINAI QUEENS FACULTY PRACTICE GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8268 164TH ST | ||||||||
| Address2: | ROOM B265 | ||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114321121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188833000 | ||||||||
| FaxNumber: | 7188836129 | ||||||||
| Practice Location | |||||||||
| Address1: | 8268 164TH ST | ||||||||
| Address2: | ROOM B265 | ||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114321121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188833000 | ||||||||
| FaxNumber: | 7188836129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | REHWALDT | ||||||||
| AuthorizedOfficialFirstName: | LISE | ||||||||
| AuthorizedOfficialMiddleName: | MARY | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR. | ||||||||
| AuthorizedOfficialTelephone: | 7188833000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 01415172 | 05 | NY | MEDICAID |